Monthly Archives: August 2015

A Comment on “Me, My Mind and Baked Beans” & “The Holocaust Intrudes…”

stone of madness     By Dr David Laing Dawson

There is no doubt we need to be careful and cautious with labels. And comparing The Holocaust (as Peter Kinderman did) to anything other than another systematic and extensive act of genocide trivializes the former and reduces whatever criticism was intended of the target to a nasty school yard epithet. It is just plain thoughtless, stupid, and insensitive – as James Coyne pointed out.

But the concept of disease is just that, a concept. The word itself is a conjunction of “dis” and “ease”. The modern concept of disease has a two or three hundred-year history. And it is, after all, the very concept that allowed us to eradicate – well, almost eradicate – measles, mumps, polio, diphtheria, cholera, to treat some cancers, heart disease, pneumonia, and to improve the lives of those suffering from the conditions of bipolar disorder, depression, and schizophrenia.

We have philosophical and scientific approaches to the concept of disease, and folk definitions. These may invoke evolution, constructivism, objectivism, adaptation, and concepts of “abnormal” and “normal”. And “normal” itself, can entail ideas of function, value, ideals, averages, and adaptation, as well as bell curves, actuarial tables, standard deviations.

The concept of disease does also imply a biological insult, difference, or malfunction of some sort, from its history of scientifically seeking cause and effect and the linkages between them, of leaving older explanatory concepts of magic, karma, miasma, destiny, god, evil, the devil and possession behind, to say nothing of the wholly unfounded notion that a “refrigerator mother” can cause autism or psychosis in her child.

We do have a recent history of overusing the disease concept in our modern world, of allowing flawed ideals and values (and commerce) to inform some of our definitions. But, in truth, it was not the overreaching concept of disease that caused damage, but the laws of the time that allowed abuse to follow. And the abuse, as is usually the case, was of power, not of semantics.

Today, on one side of the coin, we have the advocates for addictions and alcoholism petitioning for those afflictions to be called diseases, and on the other side, certain U.K. psychologists  asking that all mental disorders be removed from under the rubric of disease. The former, I’m sure, because the concept of disease does absolve one of some moral responsibility for his or her behaviour, and the latter, I’m sure, because the concept of disease requires a physician to head the team of professional helpers.

But let us bring this down to basics:

We perceive someone to be “badly off.” He may or may not perceive himself to be badly off. We then ask ourselves if the disease concept will be of benefit in this situation. Does the idea of “illness” fit? Is he suffering? Is he causing others to suffer? Folk definitions may be applied at this point: “Call the cops.” “He needs a doctor.” “He seems to be okay, he’s not bothering anybody.” “He needs his medications adjusted.” “He’s just a little eccentric.” “That’s just Joe being Joe.” Or even that contradictory but common conclusion, “What a sick bastard.”

This person is brought to or finds his way to a medical professional. The medical professional asks herself similar questions: “Is he badly off?” “Does he perceive himself to be badly off?” “Is he suffering?” “Is he causing others to suffer?” And, then, “Does the concept of disease offer any help in this situation?”

And there is absolutely no doubt (how could there be any doubt today?), that for those behaviours and experiences, those symptoms and signs and suffering that constitute severe mental and emotional disorders, that fulfill the definitions of schizophrenia, bipolar disorder, severe anxiety disorder, severe depression, the answer is YES, ABSOLUTELY.

And that ‘yes’ encompasses treatment today, and research tomorrow.

 

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Boiler Plate Speech for CEO’s

By David Laing Dawson

CEO’s of modern hospitals and corporations spend an inordinate amount of money on speechwriters, and then another large amount on speeches to undo, deny, or modify things said in previous speeches (or tweets or internal emails).

So I thought I would offer them a short speech, free of charge, that can be used in all and any foreseeable circumstances. They need merely individualize the speech by choosing what to insert within the brackets.

We are wonderful.

Our (hospital, company) strives to provide our (patients, customers) the best possible state of the art (care, equipment) on this planet and in the universe as a whole. Our (patients, customers) always come first. We have won (international, national, local Chamber of Commerce) awards for our (care, products). Safety and the welfare of all living things on this planet also come first.

Politicians may add here that they have spent more on improving (security, healthcare, product safety, education, the lives of the middle class) than the preceding three governments combined.

We welcome any external investigation into our practices and products. We have conducted our own internal investigation and have learned that we are wonderful.

If by remote chance and the unforeseeable events of uncontrollable forces in the universe it is found that one of our services or products is in any way not perfect, we will immediately rectify this.

If any inappropriate gifts have been exchanged between our employees and politicians, government officials or customers, I assure you that I, and my management team, have been completely unaware of this happening. If an employee of our (hospital, company) is found to have behaved in any way less than professional he or she will be dealt with harshly and swiftly.

And though in no way admitting any responsibility for said alleged activity, I apologize for myself, my board of directors, and my management team.

We are wonderful.

God Bless (country or city of choice).”

As For Trauma Causing Schizophrenia: No! No! No!

By Dr David Laing Dawson

Childhood deprivation and childhood trauma, severe and real trauma, can lead to a lifetime of struggle, failure, depression, dysthymia, emotional pain, addictions, alcoholism, fear, emotional dysregulation, failed relationships, an increase in suicide risk, and sometimes a purpose, a mission in life to help others. But not a persistent psychotic illness. On the other hand teenagers developing schizophrenia apart from a protective family are vulnerable, vulnerable to predators and bullies. So we often find a small association between schizophrenia and trauma, but not a causative relationship.

The human brain/mind has a large variety of mechanisms to protect itself when under threat: Avoidance, denial, withdrawal, anger, rage, fainting, fantasy, suppression, repression, derealization, depersonalization, and dissociation. Some of these may appear to be brief psychotic episodes, but they are not the same thing as persistent psychotic illness. In fact, as I have witnessed many times through the past forty years, well meaning therapists who push their patients emotionally, who “dig for underlying traumas and conflicts”, who try emotionally-laden or unstructured group therapy with patients who suffer from severe psychotic illness, invariably cause a relapse in the illness. And a relapse in schizophrenia or bipolar illness is not a benign event. This was often justified by the old psychoanalytic dogma “they have to get worse before they can get better.” Again no, no, no.

Having a psychotic illness, in itself, and the consequences of that illness, can be traumatic to both the sufferer and his or her family. People with psychotic illness do not need someone probing the wells of their psychic discomfort; they do not need (no matter how well-intended) a therapist scouring their childhood memories in search of an unhealed wound. They need support, safety, security, grounding,  and satisfying routine before they can get better. And good medical treatment.

A Psychiatrist Critiques Open Dialogue

By Dr David Laing Dawson

We humans are a strange and contradictory species. While most of us are willing to take any number of potions and pills to limit the effect of the common cold, to boost our energy levels, to ward off aging, sore joints, and failing libidos, and a great many of us are willing to consume dangerous liquids, pills, and injectables to ameliorate the anxiety of knowing we are vulnerable, mortal and inconsequential life forms, and some of us decide to undergo toxic chemotherapy for a ten percent better chance of survival, there are others of us (perhaps not different people) who would deny (proven effective) antipsychotic drugs to someone suffering the devastating and dangerous symptoms of psychosis, of schizophrenia.

Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?

To be fair we have been here before. We have all, including psychiatrists, wanted to see, to understand, mental illness, both in mild form and severe form, as adaptations and temporary aberrations of the workings of the mind. And, by extension, amenable to persuasion, love, kindness, respect, and a healthy life style. In the Moral Treatment era of the mid to late 1800’s that healthy life style was based in Christian principals of routine, work, duty, etiquette, and prayer in a pastoral setting. For someone with a psychotic illness this undoubtedly would be preferable to the imprisonment that came before, to the massive overcrowded mental hospitals that grew and grew after the industrial revolution, and even, for many, preferable to the mental health systems of 2015. But it did not treat or cure psychosis.

Through the 40’s, 50’s and 60’s many notable psychoanalysts tried treating schizophrenia with their own particular form of “open dialogue”. I read many of their books and case histories. And while they are fascinating explorations of the human condition and equally interesting attempts to find meaning within madness, it did not work, at least not as a treatment to alleviate suffering and disability.

And then in the sixties and early seventies we experimented with therapeutic communities. When I listen to the staff of Open Dialogue in Finland talking about their program I can imagine my colleagues and I saying the same things about our experience in Therapeutic Communities of the 1960’s. It was humbling, as close to a level playing field as possible, a marvelous learning experience for staff, a laboratory of interpersonal and group dynamics, an open, respectful environment for patients, but it was not an effective treatment for psychotic illness, at least not without the addition of anti psychotic medication.

Harry Stack Sullivan, a psychiatrist working before the introduction of chlorpromazine wrote that “schizophrenics are not schizophrenic with me.” And what he meant, I think, was that, with a little skill, plus respect, patience, a non-judgmental attitude, knowing when to talk and when to listen, knowing what to avoid and what to ignore, one can have an enlightening and pleasant conversation (dialogue) with someone suffering from Schizophrenia. But that conversation is not a lasting treatment or cure.

It is also notable, I think, that the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients. Now, from what I know of human nature and our tendency to round our figures up or down depending on the social moment, maybe that is 35 to 40%. And given the way they work as a 24 hour on call mobile immediate response team, with no filters for severity or urgency, even if only 30% receive neuroleptic medication, it sounds about right. In truth then, Open Dialogue in Finland is NOT not using neuroleptic medication to treat people with severe psychotic illness.

I have no doubt that they have created relationships and a social environment for their patients in which less medication is necessary to help them survive and function. I think it is the same thing our ancestors did in the moral treatment era, and again, what we did in some therapeutic communities of the 1960’s.

Open Dialogue also reminded me of some other experiments with around-the-clock, immediate response teams preventing hospitalization and achieving better results than hospitalization. When I explored some of these in the 1970’s and 1980’s wondering if they could be reproduced outside of their funded clinical trials I found young idealistic doctors and nurses quite willing at that time in their lives to be on call 24/7 without extra pay, with limited personal life during the course of the experiment. We could approximate these programs in real life but we could not replicate them.

We have ample reason to not trust big pharma and their incessant push to expand their customer base, but let us also be aware of both history, and the realities that surround us, of the many people with psychotic illness now back on the streets, in the hostels and jails, of the need for better mental health care systems, and the need for better cost effective treatment, and of the many people for whom our current medications have been both sanity and life-saving.

The Unintended Consequences of Focusing on Recovery in Schizophrenia

By Marvin Ross

Much has been said in this blog by my colleague Dr David Laing Dawson and myself on the concept of recovery. Wouldn’t it be wonderful if full recovery was possible but it isn’t. However, I really should clarify that somewhat. Schizophrenia should probably be referred to as a spectrum disorder like autism.

When Bleuler first coined the term in 1908, he referred to it as the schizophrenias and said that it was a physical disease process characterized by exacerbations and remissions. No one was ever completely “cured” of schizophrenia — there was always some sort of lasting cognitive weakness or defect that was manifest in behavior. Unfortunately, over the years, it began to be considered to be one disease only.

In a recent article in Psychology Today, University of Toronto medical historian, Edward Shorter, had this to say. In adolescent-onset schizophrenia, some don’t recover at all; others make only a “social recovery,” and some maybe go on to have a normal life or “Maybe not”. Shorter then adds that “The field has made virtually no progress in unpacking chronic severe illness and differentiating out several distinct entities. In no other field of medicine would this be conceivable!” and “Some involve loss of brain tissue, others don’t. Some have to stay on meds, others don’t. Some get well, others don’t. These are not all the same illness!”

In fact, it has long been recognized that there are three outcomes to schizophrenia. Roughly a third are treatment resistant and remain very ill, a third can be helped with meds and other treatment modalities to improve sufficiently to lead a reasonable but disabled life, and a third will have one psychotic episode, receive treatment and never have another or any long term deficits.

According to the Treatment Advocacy Center, 10 years after diagnosis, “one-fourth of those with schizophrenia have recovered completely, one-fourth have improved considerably, and one-fourth have improved modestly. Fifteen percent have not improved, and 10 percent are dead.”

How do you think the families of the majority of those with non recoverable schizophrenia or the individuals themselves will feel when we hold up to them what is achievable by only 25%? And, we tell them that it is achievable. Why can’t I (or my son or daughter) achieve that. Have I done something wrong? Cancer is an interesting analogy. There is not one cancer but many. And each cancer has its own unique characteristics and prognosis.

Non melanoma skin cancer (basal cell and squamous cell) have 5 year survivals of 95% and 90%. In contrast, the 5 year survival for pancreatic cancer ranges from 1% for stage IV to 14% from stage 1A. Imagine if we told those with stage IV pancreatic cancer not to worry because 5 year survival is 95%. Ridiculous isn’t it but that is what we tell people with schizophrenia. Don’t worry, you should be able to recover because 25% do.

Now, I’m not saying to abandon hope but rather to be realistic and pushing recovery is not realistic if it is not qualified.

The second problem was mentioned to me by my friend Kathy Mochnacki of Home on the Hill in Richmond Hill Ontario. She pointed out that if you claim that recovery is possible, then why continue doing research. People can recover so no need for it. Of course, scientists know better but they are dependent on funding from governments and other agencies.

So, let’s all inject some scientific reality into a very troubling and serious disease.